Most people consider having children at some point in their lives. For many, starting a family can be an important goal for their fulfillment and happiness. In the case of transgender people who wish to opt for a biological offspring, it is advisable that this approach is made before starting any type of body modification process, whether hormonal and/or surgical. For this reason, it is important to have good advice on reproduction and fertility in trans people.
Hormone and fertility in trans people
It is evident that the process of hormones for trans people can affect fertility in the long term. It is true that pregnancies have been described in transgender men who had already undergone hormonal treatment or even during such treatment. One of the cases, perhaps, better known in our country, is Rubén Castro, who defines himself as a non-binary transmasculine person, and who achieved his long-awaited gestational paternity in 2021 at 27 years old.
However, although it is technically possible for a trans person who retains her uterus and ovaries and who takes testosterone to ovulate and become pregnant, it would not be the most recommended way to achieve a successful pregnancy.
When you wish to become a parent and carry out a pregnancy, the process must include stopping taking testosterone, with the physical changes that this entails. In this way, if you have ovaries and a uterus, menstruation can occur and pregnancy can be attempted.
And in the case of a trans woman?
If it is a trans woman, her sperm could also be used to achieve a pregnancy, but she should also abandon hormone therapy and, even so, success is not even remotely assured.
For trans women who wish to have biological offspring, you should be aware that the use of anti-androgens and estrogen therapy has a negative effect on both testicular function and morphology. This affects both the number of sperm, as well as their maturation and motility. And although the effects may seem reversible, this is not always the case.
It is important to take into account that this whole process and the physical changes that they entail can affect psychologically to the trans pregnant person or donor, so it will need strong support from its environment.
Surgery and fertility in trans people
When the transition process includes genital surgery, this may include gonads removed. This is the elimination of the uterus and ovaries (bilateral oophorectomy/bilateral adnexohysterectomy) in trans men and the removal of the testicles (bilateral orchidectomy) in trans women. All these surgeries are considered as irreversible methods of sterility. In other words, once the surgery is done, the person will not be able to reproduce with their own gametes (eggs or sperm).
Fertility preservation options for trans people
For all this, it is very important that, prior to hormonal treatment (and even more so before the different surgical procedures that involve removal of the gonads), trans people are counseled on their options to preserve their fertility.
Basically, there are three basic options which are the following:
1. The preservation of gametes:
The gamete cryopreservation is a process by which eggs and/or sperm are obtained and are frozen to be used at the time to search for pregnancy. Obviously, gestation can only be carried out using in vitro fertilization techniques.
For trans men, the oocyte cryopreservation process it is more complex, since it requires ovarian stimulation with medication, egg aspiration to later cryopreserve them and be used at the time the person wishes to seek pregnancy. We must keep in mind that egg aspiration is a process carried out through the vagina and requires sedation.
In the case of trans women, the process is simpler, and involves an ejaculation to cryopreserve the gametes.
2. Embryo preservation:
One step further is embryo vitrification. In this option, eggs and sperm are required. Once the eggs are obtained, the mature ones are fertilized with the semen sample (either from the partner or from a donor) in a laboratory, where the embryos will develop (for 5 or 6 days). And later they will be implanted in a uterus through in vitro fertilization techniques.
3. Preservation of ovarian or testicular tissue:
In this option, the trans person who wants to be a parent undergoes surgery to remove a small portion of the ovary or testicle. This tissue is cryopreserved until pregnancy is sought, in which it can be implanted using fertilization techniques to seek pregnancy (with or without ovarian stimulation) or to try to obtain mature oocytes in the laboratory.
It is important to remember that, since 2016, the WHO recognizes the right to medical attention to all those people with a reproductive desire who, without medical intervention or technology, would not be able to reproduce. This also covers all transgender people (and in fact the entire LGTBIQ+ collective) who wish to procreate.